With increase in statics of people with diabetes, it is becoming essential to find the best approach to control the disease. This assignment will discuss how holistic assessment is an integral part of individualised care. Focusing on the case study of Chloe who has recently been diagnosed with type 1 diabetes. This assignment is structured to discuss the nursing process, Orems’ model of care and two nursing tools that can be used to achieve the wellbeing of a Chloe and relevant sources of evidence will be applied. Lastly a reflective analysis of this assignment and linked to practice that has been observed will be done.
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According to Standing 2011, nursing process was developed in the USA in the 1970s. Standing defined nursing process as a systematic and continuous cycle of problem solving, to guide individualised nursing care. Similarly Alfaro-LeFevre 2010, pointed that the nursing process consists of five interrelated steps which are cyclical. These steps included assessment, diagnosis, planning, implementation, and evaluation. They overlap each other and can be reassessed on an ongoing basis. The nursing process compliments what the multidisciplinary team do by focusing on different elements of treatment.
Hall and Ritchie (2009) pointed assessment as first step in nursing process. Patient assessment are steps taken in order to achieve the patients mental, physical, social, cultural, spiritual and personal needs and of establishing the patient’s wishes in relation to the choices or options available (Howatson-Jones et al 2012). There for Chloe needs to be assessed on these needs and her wishes will be established in relation to the options available. Patients are supposed to be in charge of making decisions about their care, hence “No decision about me without me” (Department of Health 2012). This kind of assessment is called person-centred approach or holistic patient assessment. This means that nurses have to take into account all the elements that make up the patients everyday life, including relevant family or friends, daily activities, preferences and interest. Therefore Chloe should be involved in decision making, she has to choose the option that suits her needs. In the initially assessment when Chloe visited the nurse she chose her mother to accompany her so that she can support her understand how to live with her condition. The second step in the nursing process is diagnosis. Nurses analyse data collected during assessment and determine whether they suggest normal or abnormal findings (Timby 2013). It is a health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures. Majority of people with diabetes also suffer from cardiovascular (Holt 2009). Therefore Chloe has a number of risk factors of developing cardiovascular disease. These include stress and drinking alcohol.
The third step is planning. This is the process of prioritising nursing diagnoses and collaborative problems, identifying measurable goals, selecting appropriate interventions and documenting the plan of care (Timby 2013). In Chloe’s case she needs to change her lifestyle that is to stop drinking and smoking at the same time change her diet. It is important that she gets adequate and balanced nutrition. The other plan for Chloe is to continue with checking her blood sugars and keep the food diary. Implementation is the fourth step, which means carrying out the plan of care. This involves the multi-disciplinary team and clients. In this instance medical orders as well as nursing orders complement each other. The specialist nurse has to play a significant role in making sure that Chloe follows the care plan as discussed during the assessment. The family is also involved at this step, for example Chloe’s mother promised to help her keep the food diary.
The fifth and final step of nursing process is evaluation. The nurse evaluates progress towards attainment of outcomes. The care plan can be continued or discontinued depending on the outcomes. At this stage as a nurse the focus is to find out how Chloe is copying with the care plan set for her. The entire process is like a cycle because it is ongoing as it has been mention earlier on this assignment. The nursing model provides the conceptual framework from which activity flows. (Dougherty and Lister 2008). They also pointed out that structuring patient assessment is important to monitor the success of care and to detect the emergence of new problems. Therefore if nurses are using a nursing model to frame the assessment process, it will ensure that they focus on relevant areas and are less likely to miss important cues.
Having looked at the different models of care, Orem’s model of care seemed to be the most appropriate one to assess Chloe’s condition because, Chloe needs to live a healthy lifestyle. Therefore Chloe needs to be educated that self-care in diabetes is important to keep the disease under control. Williams and Pickup (2004), pointed out that there are at least four aspects of self-care for patients with diabetes. These include self-monitoring of blood glucose, variation of nutrition to daily needs, insulin dose adjustments to actual needs and taking exercise regularly. It is known that various factors influence self-care such as emotional aspects, knowledge, physical skills and self-efficacy which have been listed as being of great importance (Hall and Ritchie (2009) As a result nurses need to collect data on Chloe’s health status, requirements for self-care and capacity to perform self-care.
Chloe is twenty years old and a third year University Student, studying for a BSc in Business Studies. Chloe lives in a shared accommodation with two friends, Sophie and Kate. Her parents live in Chester with her brother who is eighteen. Financially she manages with her student loan and wage from part-time job in a local bar. Chloe has recently been diagnosed with type 1 diabetes, she is struggling to come to terms with what this really means and how having diabetes will impact her day to day living. Chloe has many anxieties about diet, medication and lifestyle and feels unsure about her future at University.
There are number of complications of diabetes which needs to be addressed with Chloe. Majority of people with diabetes also suffer from cardiovascular (Holt 2009). Therefore Chloe has a number of risk factors of developing cardiovascular disease. These include stress and drinking alcohol. Diabetes also affect eyes, therefore the retina should be checked yearly. Williams and Pickup (2004) stressed that regular examination of the eyes in diabetic patient is very accurate and it should include visual acuity measurement with a Snellen chart. A test for microscopic amounts of albumin (a protein) in the urine should be checked yearly. An electrocardiogram should be done every 5 years. Also they will check/monitor any wounds as these will be slower to heal if diabetes is not under control. The bottom of the feet should be checked with every doctor’s visit as neuropathy may result in blisters or sores on the feet that may go unnoticed by the patient.
Holistic assessment takes into account all aspects of people’s live, the factors that affect them and what level of independence they have in these areas. Hockley and Clark 2002 cited in Hayes and Llewellyn 2010 defined holistic care as the inter-relationship between biological, psychological and social factors. The ability to successful control diabetics relies mainly upon the patient’s support system and her ability to cope with a chronic illness (Brewer 2012). So, Chloe needs her family, friends and the multi-disciplinary team to help her cope with the condition. The aims of the diabetic assessment include assessing patient’s overall physical, emotional and mental health status; determining the status of glycemic control; and assessing for any complications of diabetes and beginning treatment. She needs to recalibrate her identity and accept the condition. Referring her to social support networks will help her regain confidence and develop coping strategies. In the case of Chloe, she needs to be referred to the specialist diabetic nurse who will provide support and advice on administering insulin. Before starting the insulin Chloe has to be able to check her blood sugars and record them down.
Walker and Rodgers (2004) pointed out that single blood glucose measurements are of little use in type 1 because of unpredictable variations in blood glucose throughout the day. As a result in Chloe assessment a blood glucose monitoring chart will be used. This chart is design to monitor blood glucose four times a day. This chart also help the team on management strategies on how the patient copes different meals. For example using this chart, the doctor will be able to prescribe the right dose of the insulin depending on the recording.
According to Walker and Rodgers (2004), nutrition is a most part of diabetes care that a patient has to be aware of. Healthy lifestyle is recommended, that is balancing the right amount of portion of different nutrients like carbohydrates, fat, protein along with fibre, vitamins and minerals. For example people with diabetes, there is at least one extra consideration for their nutritional needs and that is the question of how blood sugar levels will respond to different nutrition. Chloe needs nutrition assessment in order to control her condition. The malnutrition universal screening tool will be used. This tool has five steps leading to care planning. This tool guides nurses to understand and identify patients who are at risk of malnutrition. Weight loss will also be noted. For Chloe she needs to eat healthy and avoid obesity as it is one of the factors that promote this condition.
Holt (2009), says psychosocial factors are the most important influences affecting the care and management of diabetes. Psychological support is often under-resourced and inadequate in both adults and children with diabetes. The diabetes care provider must try to target emotional well-being as part of routine diabetes management. The nurse should also ensure that psychological assessment, and treatment, are internalized into routine care, instead of waiting to identify and manage deterioration in psychological status after it has occurred. It is now proven that addressing psychological needs has a positive effect on diabetes outcomes including reduced glycosylated haemoglobin, co-morbid depression and systolic blood pressure. This also implies to Chloe who seems to be stressed.
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Checking your blood sugar (glucose) is the only way you can confidently know what your blood sugar level is at any given time. Fortunately, we now have many small, pocket-sized blood glucose monitoring devices that require only a very small blood sample.
Reflection is good way of looking back on a situation, carefully learning from it and then using the new knowledge to help you in future similar situations. Johns’ (2004) model will be used to analyse this assignment and linked to practice that has been observed. Johns’ model consists of five stages that comprise the reflection cycle (Holland and Roberts 2013). As a student nurse, I will use the headings from Johns’ model to structure my thoughts in relation to nursing practice in order to gain confidence.
Linking Chloes’ assessment with the experience gained in practice I noted that holistic focus helps to ensure that interventions are tailored to the individual, not just their condition. A patient centered approach which included all aspects of life was used to assess Chloe, this was useful in practice as I applied the same principle.
Assessing the environment before starting the procedure and making sure you have adequate access to the patient will help to improve practice. Gaining consent from the patient before beginning the procedure is following the nursing and midwifery code (2008). At the moment I work in a Gastro / Respiratory ward where a number of patient get to be diagnosed with diabetes. I also learnt that steroids can also cause rise in blood sugars hence there is need to monitor blood sugars. Before being told the diagnosis they have random blood glucose measurement taken and looking back, what is most disappointing to me is how most of them lack understanding why it is done. Therefor before they get discharged they are referred to a specialist diabetes nurse who supports and advise them, in terms of factors such as life style, nutrition, blood glucose monitoring and medication. This was the same situation in Chloes’ case study, she needed clarification on why she has to monitor her blood sugars, hence she had an appointment with a nurse where she went along with her mother who was there to support her understand her condition. In practice some patients did not have enough support from their families hence it lead for them to be admitted again within a few days of discharge. In the near future I would make sure that all aftercare has been arranged before any patient is discharged.
To conclude my essay the skill of holistic assessment is a vital one for the nurses, as we cannot always rely on doctors’ diagnosis only, but other factors in patients’ life have to be taken into consideration. I also gained that different circumstances can have an effect on the blood glucose reading. I feel I have gained a learning skill, I was quite worried about this skill but practice makes easier. The more blood glucose recordings taken, the easier the team and patient can control the condition. I also learned that different factors can affect blood glucose, for example the patient eating large meals and not eating regularly can lead to elevated blood glucose levels. It has also given me a lot of confidence in myself and confidence with the patients I care for.
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